C. Thomas Bombeck

Critical operative management of small bowel obstruction.

The records of 238 putients with the diagnosis of small bowel obstruction at the University of Illinois Hospital from 1967 through the spring of 1976 were reviewed. Mortality, intraoperative management, and clinical findings were evaluated. Previous reports list a mortality of gangrenous small bowel obstruction, secondary to hernia and/or adhesions, as >20%, although in this series, the mortality was 4.5% in patients with gangrenous small bowel obstruction. The present data reveal a 60% incidence of wound infection in patients in whom an enterotomy (iatrogenic, decompressive or resective) was made and the subcutaneous tissue and skin closed, and it is therefore recommended that the wound be left open in these situations. Although a variety of individual clinical findings have been advocated as diagnostic aids in patients with small bowel obstruction, this review suggests that attention to a combination of “classic” findings, i.e., leukocytosis, fever, tachycardia and localized tenderness, portends a situation in which conservative observation is safe—namely, the absence of all four findings. The presence of any one or more of these findings mandates early operative intervention.

A New Concept in the Surgical Treatment of Gastroesophageal Reflux

Surgical treatment of gastroesophageal reflux has been thought to depend on the construction of a valve mechanism at the gastroesophageal junction (GEJ). Recently, a silicone prosthesis that does not construct a valve has been introduced, and in preliminary studies in the human, shown to be effective in the treatment of reflux. A precise mode of action has not been demonstrated for the prosthesis. This study was undertaken to investigate the mechanics of the prosthesis and determine its effectiveness in an animal model. Six canine gastroesophageal specimens were excised and the lower esophageal sphincter (LES) simulated by a rubber band placed around the GEJ at a tension calibrated to give 25 mmHg “sphincter” pressure. Circumferential silk ligatures of varying length were then placed on the stomach 3.0 cm distal to the GEJ. With no ligature, the LES opening pressure (LESOP) was 8.0 mmHg, varying to 17.0 mmHg with an 8.0 cm ligature. Further, 24 adult mongrel dogs were randomly divided into four equal groups: controls, circular myomectomy of the LES alone, myomectomy combined with fundoplication, and myomectomy combined with implantation of the silicone antireflux prosthesis. Evaluation included manometry, endoscopy, and histology. Although only the normal sphincter and fundoplication responded physiologically, the prosthesis was just as effective in preventing reflux, as evidenced by reducing acid exposure time of myomectomized dogs from 35.4% to 1.8%, and by preventing endoscopic esophagitis. It was concluded that the silicone antireflux prosthesis acts in the same fashion as the ligature in the model, by interrupting distraction of the LES by gastric wall tension. This concept is an effective method for raising LESOP, treating experimental gastroesophageal reflux, and eliminating the sequelae of reflux. Long-term evaluations of the prosthesis are required.

Endoscopic sclerosis of the gastric cardia for prevention of experimental gastroesophageal reflux

Surgical anti-reflux therapy appears to involve the muscles of the proximal gastric cardia and those of the lower esophageal sphincter. In an experimental canine reflux model, we injected sclerosant solution into the submucosa of the proximal gastric cardia, hypothesizing that the subsequent fibrotic reaction might exert an anti-reflux effect. Reflux was induced by atropine infusion, and the amount of reflux was quantitated by pH monitoring. Endoscopic sclerosis was effective in preventing reflux induced by high-dose atropine. Because the length and pressure of the lower esophageal sphincter were unaffected by endoscopic treatment, reflux prevention was possibly related to enhancement of the gastric component of the reflux barrier.

Heterologous bovine liver perfusion therapy of acute hepatic failure

Abstract Fourteen bovine liver perfusions lasting two to six and a half hours were performed in seven patients in acute hepatic failure. All patients were in deep grade IV coma and had multiple major complications prior to perfusion. Biochemical improvement was noted in all patients; four patients had marked improvement in neurologic symptoms; two patients recovered consciousness; there were no long-term survivors. Observations related to gastric acid secretion, amino acid levels, and the effect of ATP are reported. Heterologous liver perfusion appears capable of supporting patients in pre-terminal hepatic failure for several days. Death is due as often to one of multiple complications such as gastrointestinal bleeding as it is to the primary hepatic disease.

Endoscopic Congo red test during proximal gastric vagotomy

Although proximal gastric vagotomy is widely performed as an elective treatment for duodenal ulcer, the incidence of recurrent ulcer is troublesome. There are several theories to explain recurrent ulcers, and important technical steps should be considered when performing proximal gastric vagotomy. The use of an intraoperative test may allow more accurate performance of the operation and more complete vagotomy of the parietal cell mass. This report describes the use of the endoscopic Congo red test in patients during proximal gastric vagotomy. The test allows rapid and accurate mapping of areas of the stomach with intact vagus and secretory nerves after operative vagotomy, and can be repeated several times if necessary to verify completion of the vagotomy. The use of universally available equipment and the potential for intraoperative and postoperative use are other attractive features of the test. Use of the endoscopic Congo red test provides physiologic evidence that vagus secretory nerve fibers traverse the right and left gastroepiploic nerves, leading us to believe that the gastroepiploic nerves should be routinely divided during proximal gastric vagotomy. In patients with recurrent duodenal ulcer requiring reoperation, the endoscopic Congo red test allows preoperative demonstration of the site of the intact vagal nerve trunks. The endoscopic Congo red test deserves further investigation and wider application during operations for chronic duodenal ulcer.

Can the use of an endoscopic Congo red test decrease the incidence of incomplete proximal gastric vagotomy

The endoscopic Congo red test allows accurate and rapid evaluation of the completeness of vagotomy and may result in a lower incidence of postoperative incomplete vagotomy. This report describes 44 patients tested during proximal gastric vagotomy. Evidence of incomplete vagotomy was found in over 95% at the conclusion of the conventional operation. Importantly, the test was a guide to further operative maneuvers which abolished the evidence of incomplete vagotomy upon subsequent testing. The endoscopic Congo red test satisfies the requirements for an ideal test for complete vagotomy: it is easily performed, does not require special equipment, and can be repeated several times if necessary to verify that desired effects have been achieved. The wider use of this test, therefore, appears justified.

Bladder and ureteral displacement: complication of total replacement hip arthroplasty

An unusual case of bladder and lower ureteral displacement owing to extruded cement in the pelvis through the acetabulum after total hip arthroplasty is described. The literature is reviewed.

Endoscopic sclerosis of the cardia affects gastroesophageal reflux

SummaryGastroesophageal reflux disease remains a disorder of unknown etiology associated with abnormal function of the lower esophageal sphincter (LES) and other physiological co-factors of the pathologic reflux. Effective operations for reflux are designed to reinforce the anti-reflux barrier and alter the tendency towards abnormal reflux. We have postulated that the most important component of these procedures is the prevention of distraction of the lowermost components of the LES at the onset of a potential reflux episode. Distraction of the LES causes shortening of the effective sphincter mechanism and can initiate experimental reflux events. In this study we used endoscopic sclerosis of the submucosal space at the cardia as a means of reducing distraction of the cardia in the hope that this would reduce abnormal reflux events. Canine gastroesophageal reflux was induced by intravenous atropine and monitored by continuous esophageal pH monitoring. Sclerosis of the cardia prevented gastroesophageal reflux, without measurable effect on the LES pressure or length. Endoscopic sclerosis of the cardia may be a useful technique in the control of human gastroesophageal reflux.

Effects of halothane, ether, and chloroform on the isolated, perfused, bovine liver: A comparative study

Abstract A comparative study of halothane with one known hepatotoxic agent, chloroform, and one agent for which hepatotoxicity has not been noted, ether, has been performed in the isolated, perfused calf liver. Both chloroform and ether affected carbohydrate metabolism in a manner consistent with inhibition of oxidative energy metabolism. Halothane had no effect. Both halothane and chloroform produced proliferative lesions in the smooth endoplasmic reticulum of the hepatocyte, resembling those seen with acute carbon tetrachloride toxicity and with the adaptive response to chronic phenobarbital administration. Halothane also uncoupled oxidative N-demethylation in the hepatic microsomal fraction, a result similar to those previously reported with carbon tetrachloride. Neither ether nor simple control perfusion affected these detoxification mechanisms. The implications of these findings relative to the reported incidence of hepatotoxicity after halothane administration to patients are discussed.

The effect of inhalation of halogenated anesthetics on rat liver mitochondrial function.

Liver mitochondria obtained from rats exposed to either 3 per cent or 5 per cent halothane had significantly higher rates of oxygen uptake than did those of a corresponding control series. This increased respiration occurred both in the presence and in the absence of adenosine diphosphate. No significant change in rates of respiration was found with exposure to 1 per cent halothane. The respiratory control ratio and adenosine-diphosphate-to-oxygen values were not altered by prior halothane anesthesia at any dose level used. Electron microscopic study of the mitochondria of the control and experimental groups revealed no morphologie differences. Apparently, therefore, the inhalation of halothane, as administered under the conditions of this study, does not induce any long-lasting impairment of liver mitochondrial function.